RECOMMENDATIONS OF
THE MILITARY COALITION
to the
House Subcommittee on Military Personnel
Subcommittee on Health, Committee on Veterans’ Affairs
The Military Coalition’s position
on VA/DoD health care sharing is clear. The Coalition supports any
efforts to improve coordination between the two departments, but
only if those efforts would enhance or maintain access to health
care, quality, safety, and services offered to beneficiaries of each
of the departments. It is imperative that the final outcome reflects
either a continuation of benefits at the same level or enhanced
benefits for all beneficiary populations. No decision should be
made, regardless of how "business-wise" it may seem,
unless it is clear that all beneficiary groups will not be
negatively impacted. We look to greater collaboration, not
substitution or integration as the solution.
Near-Term Opportunities For DoD –
VA Sharing
Strategic Planning. The
Coalition recommends that the government issue a strategic planning
document similar to the "National Security Strategy of the
United States" that lays out national goals and objectives for
DoD – VA collaboration and the ways and means to achieve its
stated aims.
VA’s Potential as a Tricare
Provider
The Coalition
recommends that DoD and VA jointly evaluate the current barriers to
TRICARE that inhibit the use of the VA as a TRICARE network provider
and recommends increased coordination between the VA and the TRICARE
Management Activity.
Force Health
Protection and Military Medical Surveillance System.
The Coalition recommends greater
collaboration between the DoD and VA medical systems in military
medical surveillance and force health protection since the outcome
of such work is beneficial both to national security (force health
protection) and veterans’ health care and disability claims.
Information
Management / Technology and a Common Medical Record
The Coalition strongly recommends
development and deployment of a common DoD – VA medical record as
quickly as possible, along with the capability to exchange data
seamlessly between the two systems using appropriate privacy
protections.
Pharmaceuticals
The Coalition recommends review of
the pharmaceutical practices of both departments and their mail
order pharmacies and urges improved cooperation between the two
agencies in this area.
Market-driven strategic VA/DOD
collaboration
The Coalition urges the Subcommittees
to examine the potential of an ongoing collaboration between Tri
West Health Alliance, Veterans’ Integrated Service Network (VISN)
23, and Military Treatment Facilities in the TRICARE Central Region
for its potential as a model of strategic health care planning on a
market-specific basis.
Mid-Term Opportunities For DoD – VA
Sharing
Procurement of
Medical/Surgical Supplies and Equipment
The Coalition
recommends development of a strategic plan for joint procurement of
high cost equipment and supplies, consistent with each agency’s
mission requirements.
VA Medicare
Subvention
The Coalition
continues to support testing the feasibility of using Medicare funds
in VA facilities for the non-service connected care of
Medicare-eligible veterans.
Long Term Opportunities For DoD –
VA Collaboration
The Future of Co-Located DoD – VA
Facilities.
The Coalition recommends
incorporating an independent strategic assessment of current
co-located facilities into CARES and BRAC planning.
H.R. 2667, The Dept. of Defense –
Dept. of Veterans’ Affairs Health Resources Access Improvement Act
of 2001.
The Coalition
recommends amending H.R.2667 to specify coordination of care
standards for beneficiary groups and guidance to protect earned
health care benefits for all stakeholders.
Other Concerns
Forced Choice
The Coalition strongly recommends the
Subcommittees uphold the principle that military retired veterans
have earned and deserve access to both VA and DoD care systems and
they must not be forced to forego either benefit. Budget-driven
proposals should be resolved by the DoD and VA and not visited on
the backs of those who earned those benefits through service to
their country.
Demographic Tracking of Dual-Eligibles
The Coalition
recommends development of better data on military retiree usage of
VA care in order to obtain a more accurate picture of demand and
cost on that system and improved reimbursement planning between DoD
and VA.
Conclusion
DoD and the VA have reported through
the Executive Council on ways they are collaborating in contracting,
administrative and maintenance services, and purchasing. The
Coalition is hopeful that these arrangements, if properly
administered and evaluated, could provide models for future
collaboration. We believe the two systems can and should work closer
together to develop health care quality measures, graduate medical
education, and centers of excellence for certain specialty care. The
Coalition requests, however, that the Subcommittees encourage
collaborative ventures as part of an overall strategic initiative
with a primary focus on the needs of each system’s beneficiaries.
VA/DOD HEALTH CARE
COORDINATION
The Military Coalition’s position
on VA/DoD health care sharing is clear. The Coalition supports any
efforts to improve coordination between the two departments, but
only if those efforts would enhance or maintain access to health
care, quality, safety, and services offered to beneficiaries of each
of the departments. It is imperative that the final outcome reflects
either a continuation of benefits at the same level or enhanced
benefits for all beneficiary populations. No decision should be
made, regardless of how "business-wise" it may seem,
unless it is clear that all beneficiary groups will not be
negatively impacted. We look to greater collaboration, not
substitution or integration as the solution.
NEAR-TERM
OPPORTUNITIES FOR DOD – VA SHARING
Strategic Planning
The Coalition supports a strategic
analysis of collaboration from the standpoint of how the
headquarters levels of both the Department of Defense and the
Department of Veterans’ Affairs can empower local leaders to work
together, holding them accountable for delivering quality health
care for both DoD and VA beneficiaries. By thinking strategically
while always focusing on desired beneficiary outcomes such as health
status and patient satisfaction, the departments can significantly
increase collaborative efforts to the advantage of not only the
beneficiaries but also for the two systems, as well as the American
taxpayers.
In practical terms, a strategic
approach to collaboration means defining "joint"
requirements that are derived from each agency’s unique missions.
For example, DoD and VA’s missions intersect in the areas of
medical research, graduate medical education, mass casualty
management, military medical surveillance, and now homeland defense
collaboration. Yet, there is no national level policy document (such
as "The National Security Strategy of the United States")
that adequately spells out how these common mission areas are to be
translated into specific requirements along with the capabilities
and resources to carry them out in the nation’s best interest.
Many studies have "come and gone" on the need for
improving the planning process between DoD and the VA, but until
collaboration is directed at the highest levels of government,
all of the historic and cultural reasons for not working together
will prevail.
The Coalition recommends that the
government issue a strategic planning document similar to the
"National Security Strategy of the United States" that
lays out national goals and objectives for DoD – VA collaboration
and the ways and means to achieve its stated aims.
The Coalition maintains that there
are significant near-term opportunities that would allow for
increased collaboration between the two departments and improve
beneficiaries’ health care. These include:
1. VA as a TRICARE
network provider
2. Force Health
Protection and Military Medical Surveillance System
3. Information
Management / Technology and a Common Medical Record
4. Pharmaceuticals
5. Market driven
strategic VA/DOD collaboration.
VA’s Potential as a
Tricare Provider
The VA’s role as a TRICARE network
provider is a potential source for increased access to quality
health care for all DoD beneficiaries. If VA’s capacity allows,
and its core mission is not compromised, then the VA should play a
vital role in offering primary and specialized care to TRICARE
beneficiaries as a network provider.
In a June 1995 Memorandum of
Understanding, TRICARE contractors were authorized to include VA
medical centers (VAMCs) in provider networks and, therefore, TRICARE
contractors were encouraged to use VA facilities. Due to persistent
billing and reimbursement problems, VA’s potential as a network
provider has not been fully realized. Despite 80% of VAMCs currently
being considered TRICARE network providers, three-quarters of the
activity occurs in only 26 facilities and the total level-of-effort
was miniscule according to the GAO (May 2000).
Current TRICARE contracts will begin
to expire over the next few years, and the Coalition is pleased that
the VA is represented in the new contract development. TRICARE
Management Activity (TMA) has acknowledged the importance of
considering the VA in the next generation of contracts. In light of
the growth of VA’s Community Based Outpatient Clinics (CBOCs), the
VA could be a service delivery alternative for TRICARE beneficiaries
where capacity exists.
The Coalition supports greater
utilization of VA networks in partnership with TRICARE. Although
many VA providers are also TRICARE network providers, actual usage
has been marginal. Some of the reasons why this partnership has not
been fully realized include:
· VA providers are not qualified in
specialties most in demand by DoD beneficiaries. i.e. pediatrics and
obstetrics and gynecology
· VA providers often cannot meet
TRICARE Prime access standards
· Business practices in the areas of
claims processing, IM/IT systems’ incompatibility, conflicts over
pricing of services, various administrative limitations and a lack
of aligned incentives impede use of VA providers by TRICARE Managed
Care Support Contractors
Expanding the use of VA providers as
TRICARE-authorized providers to care for all TRICARE beneficiaries
may improve active duty and retirees’ access to care in areas
where TRICARE Prime is not available.
The Coalition
recommends that DoD and VA jointly evaluate the current barriers to
TRICARE that inhibit the use of the VA as a TRICARE network provider
and recommends increased coordination between the VA and the TRICARE
Management Activity.
Force Health
Protection and Military Medical Surveillance System.
DoD and VA have been collaborating
more in recent years on research into operational health-related
issues. For example, there are a number of ongoing studies on the
causes and treatment of symptoms known collectively as Gulf War
illness.
This work is valuable to DoD’s
readiness mission since a critical aspect of medical readiness is to
develop "force health protection" strategies that preserve
the fighting force and effectively use the right medical
capabilities to support deployed troops. VA’s stake in this work
is to improve health care delivery for service-connected veterans
who have been deployed to various operational environments during
their service and to facilitate the adjudication of claims for
service connected disabilities.
In a recent report (October 16,
2001), the GAO reported that a "medical surveillance system
involves the ongoing collection and analysis of uniform information
on deployments, environmental health threats, disease monitoring,
medical assessments, and medical encounters." The report states
that some progress has been made in developing such a system but
points out that there remain significant gaps. The report notes that
the Gulf War "exposed many deficiencies in the ability to
collect, maintain, and transfer accurate data describing the
movement of troops, potential exposures to health risks, and medical
incidents in theatre." Without reliable deployment and health
care information, it was "difficult to ensure that veterans’
service-related benefits claims were adjudicated
appropriately."
The Coalition recommends greater
collaboration between the DoD and VA medical systems in military
medical surveillance and force health protection since the outcome
of such work is beneficial both to national security (force health
protection) and veterans’ health care and disability claims.
Information
Management / Technology and a Common Medical Record
The FY 2002 National Defense
Authorization Act includes a provision (Section 734) that encourages
an ongoing pilot program in which the VA conducts separation
physicals for the DoD. A software program developed to support the
pilot project creates data needed by DoD for the separating
servicemember and concurrently provides the VA with the information
needed to make a disability determination. The project eliminates
the need for a second physical exam performed by the VA after
separation and standardizes a "one exam" process.
Earlier efforts have not been as
encouraging. In 1997, the administration directed development of a
"comprehensive, life-long medical record for each service
member." In January 1998, the VA, DoD, and IHS initiated the
Government Computer-Based Patient Record (GCPR) project. Later that
year, the two agencies were directed to develop a
"computer-based patient record system that will accurately and
efficiently exchange information." Initial plans for the
project called for its deployment by October 1, 2000, but
intermediate target dates were not met. The project now has no
defined implementation date. The GAO reported the following problems
with the GCPR project in its evaluation:
1. GCPR’s cost
estimate jumped from $270 million in September 1999 to $360 million
in August 2000. Even the 2000 estimate was believed to be
understated.
2. The project
encountered setbacks due to inadequate accountability and poor
planning.
3. At the time, only
VA had the capability of sharing certain information across its own
regions; DoD’s TRICARE regions were unable to share beneficiary
health information between them.
4. In the interim
effort, requested information took as long as 48 hours to receive.
5. It will not be
possible to organize or manipulate the transmitted information.
Terms and their contexts are not
standardized across VA and DoD, thus making the information
meaningless when transmitted.
Notwithstanding these challenges,
development of a common DoD – VA medical record has the potential
to improve the efficiency and effectiveness of both the VA health
care and claims systems, lower DoD and VA medical expenditures,
facilitate data exchange for research and other purposes, and help
servicemembers and veterans get better health care and prompt,
accurate disability decisions.
The Coalition strongly recommends
development and deployment of a common DoD – VA medical record as
quickly as possible, along with the capability to exchange data
seamlessly between the two systems using appropriate privacy
protections.
Pharmaceuticals
There are two ways in which the VA
and DoD can improve coordination of their pharmacy programs. The
first is to increase its joint procurement contracts for common
pharmaceuticals, and the second is to provide a link between, or
even combine, the departments’ mail order pharmacy programs. Both
departments currently have a mail order pharmacy program, but
neither program is able to communicate with the other. The Coalition
believes that both the VA and DoD can save millions of dollars by
sharing these pharmacy distribution programs.
The VA currently has a
well-established Consolidated Mail Outpatient Pharmacy (CMOP)
program, which is considered to be highly efficient and
cost-effective. Beginning April 2001, DoD implemented its Senior
Pharmacy program, which allowed retirees over 65 to become eligible
for use of its National Mail Order Pharmacy (NMOP) and TRICARE
network pharmacies. With this program, all DoD beneficiaries now
have access to the NMOP and network providers. However, VA
beneficiaries are not eligible to use the NMOP, and DoD
beneficiaries are not eligible to use the CMOPs.
DoD has conducted an assessment of
the costs and time required to develop a computer interface between
DoD’s military pharmacies and VA’s Consolidated Mail Order
Pharmacy (CMOP) centers. According to the GAO, DoD has determined
that it is feasible to develop the necessary computer interface
between military pharmacies and CMOP centers, but it has not
developed an implementation plan. DoD is in the process of planning
to seek funding for the project. Enhancing the interoperability of
the pharmacy programs will both improve the delivery of pharmacy
benefits and yield a cost savings for both departments.
Aggressive efforts are being made to
jointly procure pharmaceuticals; however, both DoD and VA have
conveyed to the GAO the following problems with jointly procuring
pharmaceuticals:
1. Culture differences make it
difficult to come to an agreement.
2. Beneficiary populations are
different for both systems; therefore their pharmaceutical needs
vary too much to combine the program.
3. The scope of each of their
formularies varies so much to the degree that joint drug procurement
would be limited.
4. Joint contracts would result in
closing some pharmaceutical classes, which would be clinically
unacceptable for certain populations.
5. DoD has limited control over
private providers’ prescribing practices.
The GAO reported that
many of these obstacles can be overcome, and that DoD’s use of the
CMOPs would cut current dispensing costs and increase patient safety
and convenience
Compatibility of pharmacy records
systems would allow the VA to fill prescriptions that are written by
non-VA doctors. Currently, a VA doctor must review the patient’s
medical record and write the prescription for it to be filled at a
VA pharmacy. DoD’s direct care and retail pharmacies fill
prescriptions from non-military providers, honoring prescriptions
written by civilian licensed providers.. DoD's Pharmacy Data
Transaction Service (PDTS) maintains a patient medication record, or
profile, for all DoD beneficiaries to coordinate pharmacy delivery
worldwide. Having common access to patients’ health records, such
as. PDTS could be the first step in permitting beneficiary access
through both systems.
The Coalition recommends review of
the pharmaceutical practices of both departments and their mail
order pharmacies and urges improved cooperation between the two
agencies in this area.
Market driven strategic VA/DOD
collaboration
The Coalition is aware of a program
currently in place termed the Central Region Federal Health Care
Alliance (CRFHCA), whose focus is to foster collaboration between
the Department of Defense, the Department of Veterans Affairs and
the TRICARE Central Region managed care support contractor (TriWest
Healthcare Alliance). This group has come together to maximize the
use of federal resources in meeting the health care needs of all
stakeholders. The Coalition believes that the CRFHCA model has great
potential for immediate application in several local markets.
The first project is in Veterans’
Integrated Service Network (VISN) 23, which includes North and South
Dakota, Minnesota, Nebraska and Iowa. The TRICARE Lead Agent, the
VISN Director, and the MTF commanders from Ellsworth AFB, Grand
Forks AFB and Minot AFB, as well at TriWest Healthcare Alliance
together are discussing specific areas for coordination to include
sharing resources and services: catastrophic case management,
telemedicine, radiology, mental health, data and information
systems, prime vendor contracting, joint provider contracting, joint
administrative processes and services, education and training. The
next step is to expand to Colorado Springs later this year.
The Coalition urges the Subcommittees
to examine the potential of an ongoing collaboration between Tri
West Health Alliance, Veterans’ Integrated Service Network (VISN)
23, and Military Treatment Facilities in the TRICARE Central Region
for its potential as a model of strategic health care planning on a
market-specific basis.
MID-TERM OPPORTUNITIES
FOR DOD – VA SHARING
1. Procurement of
medical/surgical supplies and equipment
2. VA Medicare
Subvention
3. Access Standards
and Coordination of Care
Procurement of
Medical/Surgical Supplies and Equipment
The Coalition believes that there is
considerable potential for the two departments to jointly procure
medical/surgical supplies and equipment. In general, purchasing in
large quantities is more cost effective acquisition in lower numbers
of units. Therefore, any opportunity for both agencies to combine
their purchases of medical/surgical supplies and medical equipment
could lead to maximizing economies of scale for both agencies.
In regard to certain expensive, high
technology items such as MRIs or CT machines, there may be a lack of
market competition and little opportunity to maximize economies of
scale; therefore, combined purchasing for these items may not
provide a cost savings. However, areas where VA and DoD facilities
are collocated, sharing of equipment may be a more feasible option.
If a institution has a high-ticket item such as an MRI unit that is
not already operating at full capacity, incorporating beneficiaries
from the other agency could lead to more efficient use of the
equipment. The other agency would not necessarily have to purchase
high-priced equipment to fill a limited need. Expensive technology
that is used to its maximum capacity can justify significant
acquisition investment.
The Coalition
recommends development of a strategic plan for joint procurement of
high cost equipment and supplies, consistent with each agency’s
mission requirements.
VA Medicare
Subvention
In recent years, the House and Senate
have passed VA subvention in separate sessions, but have not been
able reach agreement on a design to test the use of Medicare funds
in VA facilities. Medicare Subvention could prove beneficial to the
government and stakeholders.
For veterans, VA Subvention would
mean improved access to care, as nearly 60% of enrolled veterans are
Medicare eligible. These beneficiaries have paid into Medicare
throughout their working lives. One important question that needs to
be evaluated is whether the VA can deliver Medicare-sponsored
services more efficiently than Medicare in the private sector.
A test would demonstrate whether
Medicare funds already being spent in the private sector could be
more efficiently used in the VA setting for Medicare-eligible
veterans. The Coalition recommends a test to determine whether VA
subvention can indeed deliver a "win-win-win" for
Medicare, the VA health care system, and Medicare-eligible veterans.
Today, many Medicare-eligible
veterans use VA health care for some services and Medicare HMOs or
fee-for-service for the rest of their care. The result is
inefficiency, duplication of effort, inconsistency, and patient
safety concerns. A recent VA study revealed that the number of
veterans who receive care from the VA and care from a Medicare HMO
is "increasing rapidly". The study showed that:
· VA patients covered by Medicare
HMOs already receive substantial amounts of VA care.
· Estimated Medicare
payments to Medicare HMOs on behalf of veterans who seek care from
both government providers were $305 million in one year (FY 1996).
· For
veterans covered by Medicare HMOs for a one-year period (FY 1996),
VA spending on Medicare services to those same veterans totaled $146
million.
VA data shows that enrollment of
veterans in Medicare HMOs is increasing in areas of the country
where VA resource allocations are decreasing. In the study, the
proportion of Medicare-eligible VA patients enrolled in Medicare
HMOs in the Northeast was up significantly. But in the corresponding
VA networks, VA funding was on the decline. The study showed that
Massachusetts Medicare enrollment increased from 3.0% to 12.2%; New
York from 4.1% to 4.9%; New Jersey, 0.6% to 8.3%; and Pennsylvania,
2.3% to 13.2%.
VA Funding in the
corresponding VA Networks from FY 1996 – 1999 was down:
-- Boston (VISN 1) - 8.0%,
-- Albany (VISN 2) - 5.8%;
-- Bronx (VISN 3) - 6.9%;
-- Pittsburgh (VISN 4) - 2.0%;
-- Baltimore (VISN 5) - 11.0%.
This may mean that overall government
spending for Medicare-eligible veterans is simply being shifted away
from the VA to Medicare in certain regions, with no gain in
productivity.
In the context of rising Medicare
enrollment and regional decreases in VA funding, a Subvention test
would determine if veterans would choose VA health care as their
primary source of care and if overall government spending for
Medicare-eligible veterans’ care could be reduced.
A VA Subvention test also would
evaluate the economic dynamics in VISNs where there is rapid
enrollment and funding growth. A test would determine whether
government resources can be used more efficiently in regions with
growing veteran populations. The same VA study showed that the
proportion of Medicare eligible VA patients who are also enrolled in
Medicare HMOs is significant in those areas where VA funding
allocations are increasing.
The following table illustrates this:
Percent of Medicare-Eligible
Veteran Patients Also Enrolled in Medicare HMO
